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In a recent letter Sir David Nicholson began to make clearer how he sees the NHS commissioning board and GP commissioners working together. It is a very important letter and warrants reading very carefully. The appointment of Sir David as the Chief Executive designate of the NHS commissioning board, late last year, seemed to signal that government had realised that management of a health system, through such considerable reforms at a time of severe economic challenge, required some continuity, standardisation, and grip.

What I think the letter sets out very clearly is the commissioner-provider split within the system. Provision will be within an economically regulated market, driven by choice and competition. Commissioning won’t. The letter articulates a vision of integrated commissioning so that, “the end-point will be a single organisation covering the whole country and supporting a vibrant system of local consortia: the NHS Commissioning Board.”

The NHS commissioning board, it has been made clear, will have the power to authorise consortia, to confirm (or reject) the appointment of the accountable officer and it will “provide a national framework for local commissioning.” Probably the most important sentence in the letter for GP consortia is, “So while consortia will have the freedom to shape services and drive improvements locally, they will do so within a national framework and with support and guidance from the NHS commissioning board. This will mean creating an integrated system between consortia and the board, which supports the delivery of national accountabilities as well as local priorities.”

It seems to me that, potentially, this transforms the NHS from being about providers to one that is predominantly concerned with commissioning. Within the letter Sir David talks about how, “The board will safeguard the core values of the NHS, ensuring a fair and comprehensive service across the country and promoting the NHS Constitution.” He indicates that this, “means moving from a system configured to diagnose and treat, to one configured to predict and prevent. And it means driving the improvements in clinical care that will have the greatest impact on improving quality and value, particularly by transforming the management of long-term conditions, moving services closer to patients, and containing demand for urgent care.”

This is a very bold and exciting vision that needs to be understood, accepted, and championed by clinicians if it is to be realised. It will require skilled management at a local level by leaders, both clinicians and managers, who understand the bureaucracy and can acquire the confidence of the NHS commissioning board that they know what they are doing and what they need to do.

By 2013 there will be one integrated commissioning organisation for the NHS in England with the NHS commissioning board at the heart and soul of the NHS.

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.